_____ of the frontal sinuses occurs with normal or slightly thickened mucosa

2-3

Otoscope will view the anterior nares, the first _____cm

ENT physical exam

Nasal speculum with light; Anterior rhinoscopy: Visualization of the septum, inferior and middle turbinates. Portions of the nasopharynx and limited view into the middle meatus. Posterior rhinoscopy with a tongue blade, nasopharyngeal mirror and headlight can view the posterior choana, nasopharynx, eustachian tubes, posterior edge of the septum and inferior turbinates

May accompany almost any pathology of nose, nasopharynx, or paranasal sinuses. Most common cause is break in prominent capillary vessels along the anterior septum (Kiesselbach's Plexus or Little's Area). Most common site of bleeding is Kiesselbach Plexus. Usually with local trauma (Digital Extraction, nose blowing, sneezing, Foreign Body, infection, allergic rhinitis). If the scab dislodges, bleeding may recur. Systemic causes (anticoagulation, coagulopathies)

epistaxis

tx: Inspect and evacuate clots by suction. Patient seated upright apply firm pressure to the nares for 10-15 mins. Identify the site of bleeding and anesthetize with lidocaine. Cauterize w/ a silver nitrate stick. Place packing and leave in for 24 hours. Topical vasoconstrictive agents oxymetazoline - 2 sprays every 12 hours for 3 days can be helpful if persistent. Improve humidity. Petroleum jelly. Nasal saline sprays and water based lotion can prevent recurrences. education important

posterior epistaxis

Woodruff's plexus. Uncommon and significant. The bleed cannot be visualized by anterior rhinoscopy. More common in adults. Cause: Acute trauma and bleeding. Generally arterial. Presentation: Blood may be seen in the posterior pharynx. May cause airway compromise

posterior epistaxis

tx: Often requires ENT consult. Posterior packing placed. Monitor for Toxic Shock Syndrome from retained packing. Often admitted, placed on supplemental oxygen and monitored for hypoxemia. Antibiotic often used. Last resort is ligation of the internal maxillary and ethmoidal arteries

_____ _____ may cause bleeding along the defected portion of the septum

sinusitis

Blood with purulent drainage suggests acute _____

t

t/f: Tumors are a rare cause of nasal bleeding

juvenile nasopharyngeal angiofibroma

Adolescent male with profuse bleeding consider _____ _____ _____

acute viral rhinosinusitis

aka the common cold. inflammation of all mucosa of nose and paranasal sinuses. Cause: Rhinovirus, coronavirus, respiratory syncytial virus (RSV), additional viral causes. Rhinoviruses cause at least ½ of all common cold illnesses

acute viral rhinosinusitis (the common cold)

Sx: Malaise, fatigue, occasionally a low grade fever possible (>38C suggests influenza or bacterial infection), chills, cough, sore throat. Nasal sx: obstruction, clear rhinorrhea, pressure over sinuses, blocked ears, stuffy nose. In children a fever for the first 2-3 days is not unusual. Anterior cervical lymph node enlargement can occur. Cold may last 10-14 days in infants and children

Supportive tx; septal hematoma refer ENT emergently. (septal widening may indicate septal hematoma. Refer to prevent saddle nose deformity). Cold compresses. Reduction of the fx is done 4-8 days after the injury to allow swelling to decrease. Repair is needed if obstruction of the airway

sinusitis

Inflammation of the sinus cavities. Can be acute or chronic. Usually occurs after an upper respiratory infection (URI). Risk factors include: Recent URI, chronic sinusitis, smoking, history or trauma or foreign body

sinusitis

Causes: Strep pneumoniae, H. flu, M. catarrhalis, S. aureus. It could also be due to a dental infection. Foreign bodies. Viruses: rhinovirus, influenza/parainfluenza, RSV, adenovirus, coronavirus, enterovirus. Viral more common than Bacterial

Sinus films are not generally useful. CT scan - may show opacification. Referral:More than 3 cases of sinusitis per year. Severe infection that fails to be treated by abx. Persistent infection despite a few adequate trials of abx

complication of frontal sinusitis with swelling in forehead due to osteomyelitis in frontal bone

fungal/mycotic sinusitis

Almost exclusively in immunocompromised or diabetic patients. More common in warm, humid climates. Consider if typical treatment fails. Causes: Aspergillus is most common, Coccidiomycosis, histoplasmosis, sporotrichosis, cryptococcosis, and othersTx: Surgical Drainage is the treatment of choice

Deviation from midline from trauma or disproportionate growth between the facial skeleton and nasal septum. Trauma or development. May lead to ostial obstruction or sinusitis

deviated septum

Unilateral or bilateral obstruction with symptoms. Diagnosis made by history and physical. Anterior deviations with worse symptoms than posterior. Treatment:only required if there is obstruction present. Septal deformity is a minor elective surgical procedure under local anesthesia. External nasal deformity may undergo rhinoplasty

Diagnosis based on history of chronic nasal obstruction associated with turbinate hypertrophy. Failure to respond to decongestants, antihistamines, or intranasal steroids leads to different surgeries to correct

Inflammatory disorder of unknown etiology. Possibly due to chronic inflammation. Histamine may play a role. Often seen with allergic rhinitis. May be single or multiple. Originate from sinus mucosa, appearing gray translucent pedunculated masses. Symptoms are obstruction, hyposmia, anosmia, congestion, infections. Nasal phonations and complain of constant congestion

nasal polyps

Dx: Made by rhinoscopy or nasal endoscopy. Bx to r/o malignancy if there is a unilateral or solitary mass. Tx: Management aim is control of symptoms; topical/oral steroids. Surgery where indicated. Frequently recur. ENT for surgery

Same symptoms as allergic rhinitis but allergy testing is negative. No eosinophils on nasal smear. Tx with decongestants

vasomotor rhinitis

Increased secretion of mucus from the nasal mucosa. May be from changes in temperature or humidity, odors, alcohol, or from a neurovascular imbalance. Bogginess of the nasal mucosa with complaints of stuffiness and rhinorrheaSymptoms can clear quickly. tx: Avoid the irritant. Decongestants

rhinitis medicamentosa

Overuse of decongestant drops or sprays (phenylephrine and oxymetazoline). Rebound congestion prompts increased use of the agent which creates a vicious cycle. Presentation: Severe congestion and pain. Minimal discharge. Tx: Discontinue the irritant. Consider topical steroids during the withdrawal period

Cause: Coxsackievirus A; Fall and Summer. Presentation: Severe sore throat, odynophagia, sudden high fever, malaise, dysphagia, vomiting, anorexia. Child is irritable due to pain. Primarily children less than 5 years old. Oropharynx has numerous small vesicles that are gray/white with red halos, then become flat. Linear arrangement on the palate, uvula, tonsillar pillars. Diffuse pharyngeal hyperemia. Oropharynx! Usually less than one week. Acute onset. tx:Self-limiting; supportive and symptomatic treatment with antipyretics, fluids

Affects 20% of the population. Occur on all areas of the oral mucosa except the hard palate, gingiva, and vermilion which are keratinized. They are in 3 clinical forms: Minor, Major, and herpetiform. Failure to resolve should prompt incisional biopsy to exclude neoplasia

Primary Herpetic Gingivostomatitis

Herpes simplex virus type I most commonly. Presentation: painful oral lesions. Children most common. Most people are exposed during childhood. Many painful lesions on the buccal and gingival mucosa. Vesicles coalesce to form ulcers. May have fever, arthralgia, malaise, cervical lymphadenopathy. Fever and malaise, any oral mucosal site. Tx: Self-limited and Lasts 7-14 days. Treatment supportive and symptomatic. Early treatment with acyclovir suspension swish and swallow can shorten duration

hsv-1

cold sores: secondary lesions. Recurrent, episodic eruptions of yellowish fluid filled vesicles on upper/lower lip, nose. Most common: lip. Less common on the keratinized mucosa of the gingiva or hard palate. Usually a prodrome of tingling, burning or itching occurs before the episode. Stress, immunosuppression, trauma, sunlight exposure. Topical acyclovir ointment can be affective for mucosal lesions. Systemic acyclovir within 72 hours of onset can help. Fluids, rest, analgesics, antipyretics. Avoid herpetic whitlow

Infection: Often Candida or Staph. Thumb sucking. Sagging face and loss of teeth. Presentation: Dry, burning at the corners of mouth. Often associated with oral candidiasis. Macerated, deep fissures at the mouth corners. Tx: Identify and treat the cause. Clotrimazole 1% cream if the etiology is Candida

Often in immunocompromised or with use of broad spectrum antibiotics. Burning pain of the tongue, inside cheeks, throat. Can be scraped off and the area underneath will be red, friable, raw. Tx: Nystatin (antifungal) swish and swallow. Clortrimazole, Fluconazole

May be asymptomatic, hoarseness, voice changes. May be Isolated to vocal cords or larynx diffusely. Keratinization of the mucosa occurs. It may involve dysplastic epithelial changes. Painless white patch on the tongue, inside cheek, lower lip, floor of the mouth and it CANNOT be scraped off

leukoplakia

May be considered a premalignant lesion. Carcinoma develops in 2% to 6%. Erythroplakia has a 60% rate of changing to malignancy. Excisional biopsy both diagnostic and therapeutic, especially in those with a history of alcohol and tobacco use. Laryngoscopy to observe for recurrence or progression

Parotid gland is the most common site of involvement. Any age but most common between 55-65 years of age. Many tumors of the parotid are benign. The 3 most common types of malignant tumors of the salivary glands are; adenoid cystic carcinoma, mucoepidermoid cancer, adenocarcinoma. Adenoid cystic carcinoma can spread hematogenously, and along the nerves. Alcohol and tobacco are the main causes. Surgical removal and possibly radiation. Response rates of 20-35%, but some prolonged responses are occasionally seen